Expansive laminoplasty for lumbar intradural lipoma

Surgical strategies and outcomes for intradural lipomas over the past 20 years

Intradural lipoma is an extremely rare spinal tumor. The boundary between the spinal cord and the lipoma is usually unclear, with adhesions being firm. Thus, total resection of the tumor is difficult and the neurological prognosis after total resection is poor. Information on the management of this type of tumor is scarce owing to the limited studies that have been conducted and the low sample sizes reported. Here, we report a case and provide a review of the literature on intradural lipomas over the past 20 years. In addition to describing our case, we reviewed reports published in Pubmed and CiNii. The demographic data of the patients included in these studies were extracted and the surgical procedures were assessed, along with their corresponding postoperative outcomes. There were 57 primary cases and 4 cases of recurrence. Among the primary cases, the neurological symptoms were persistent in 54 (95%) after surgery. The postoperative outcomes after excessive (>60% tumor resection) or total resection were significantly poor. In the recurrence cases, the mean period from initial surgery to recurrence was 11 years and all initial surgical procedures involved only partial resection surgery. This report is, to the best of our knowledge, the most exhaustive analysis of cases of intradural lipomas and recurrences. The optimal treatment for lipoma necessitates both partial resection and duraplasty.

Massive bilocular spinal cord intramedullary lipoma of the thoracic spine

Spinal cord intramedullary lipomas are rare, comprising 2% of intramedullary tumours. They are more often associated with spinal dysraphism, while lipomas not associated with spinal dysraphism are even less frequent, accounting for 1% of cases. The pathogenesis of spinal cord intramedullary lipomas remains unclear. MRI is the gold standard for the evaluation of these lesions. We hereby present a case of a 37-year-old male, who underwent MRI due to spastic paraparesis. MRI revealed a bilocular, spinal cord intramedullary lesion at the level of T ₂-T ₅, with dilatation of the spinal canal and signal characteristics compatible with lipoma. There was no clear imaging evidence of spinal dysraphism. The patient underwent surgery and diagnosis was confirmed histopathologically.

Two one-stage posterior approaches for treating thoracic and lumbar spinal tuberculosis: A retrospective case-control study

The aim of this retrospective study was to analyze the results of two surgical treatments for thoracic and lumbar spinal tuberculosis. A total of 73 patients with monosegmental thoracic or lumbar spinal tuberculosis were enrolled from January 2006 to April 2011. The patients were divided into two groups. Patients in group A (n=34) underwent one-stage posterior debridement, limited decompression, bone grafting and internal fixation combined with lamina reconstruction, while those in group B (n=39) underwent one-stage posterior debridement, decompression, bone grafting and posterior instrumentation. Clinical and radiographic results were analyzed and compared between the groups. Patients were followed for a mean 31.3 months (range, 21-42 months). Fusion occurred at 4-12 months (mean, 7.7 months). Surgical complications affected one and five patients in groups A and B, respectively. There was extraction of internal fixation in two group B patients. Postoperatively, there was significant Cobb angle correction in the two groups. By the last follow-up, the Cobb angle and correction loss in group A were significantly better than that in group B; the group A Oswestry Disability Index and Frankel grade were better than that in group B. In conclusion, one-stage posterior limited decompression, bone grafting and internal fixation combined with lamina reconstruction enables rapid management of monosegmental thoracic and lumbar spinal tuberculosis with fewer complications and minimal invasion.

Novel surgical approach in the management of longitudinal pathologies within the spinal canal: the split laminotomy and "archbone" technique: alternative to multilevel laminectomy or laminotomy

Multilevel laminectomy to open the spinal canal carries the risk of spinal deformities and instability. With the aim of preserving and reconstructing the posterior structures the authors developed a novel, minimally invasive, multilevel spinous process splitting and distracting laminotomy approach with or without complementary corticocancellous iliac crest or PEEK cage "archbone" grafting. The technique allows exploration of the spinal canal and the removal of intramedullary pathologies. Moderate enlargement of the spinal canal with preservation of the majority of posterior structures is also possible, so that muscle attachments remain intact and postoperative complications are substantially reduced.This surgical approach, while fulfilling the requirements of previous laminotomy techniques, helps to prevent damage to the crucial posterior stabilizers of the spine. In contrast to conventional spinal canal approaches, preservation of the majority of posterior structures is possible, leaving muscle attachments on the spinous processes and laminae completely intact.Furthermore, the procedure for exposure and decompression of the spinal canal is a suitable method for all spinal segments, the cervical, thoracic, and the lumbar spine in all age groups.

Application of lamina replantation with ARCH plate fixation in thoracic and lumbar intraspinal tumors

The aim of the present study was to investigate the clinical effects of lamina replantation with ARCH plate fixation on patients with thoracic and lumbar intraspinal tumors, following laminectomy. Thirteen patients with thoracic and lumbar intraspinal tumors underwent total lamina replantation with ARCH plate fixation and repair of the supraspinous ligaments, following laminectomy and tumor enucleation. To investigate the clinical effect of lamina replantation with ARCH plate fixation, pre- and postoperative visual analog scale (VAS), and Oswestry Disability Index (ODI) scores were determined, and pre- and postoperative X-ray and magnetic resonance imaging (MRI) examinations were conducted. Computed tomography (CT) examinations were also included in the follow-up. No complications were observed pre- or postoperatively. The VAS and ODI results 2 weeks following surgery and at the final follow-up examination demonstrated a significant improvement compared with the corresponding preoperative results. The X-ray examination results indicated a satisfactory internal fixation location, without any characteristics of a fracture, lumbar scoliosis, kyphosis or instability. Following the surgery, the CT and MRI examination results demonstrated that healing of the lamina bone and repair of the supraspinous ligament had occurred without tumor recurrence or spinal epidural scar recompression. Two of the 13 cases were lost to follow-up. The results indicated that in patients with thoracic and lumbar intraspinal tumors, lamina replantation with ARCH plate fixation following total laminectomy is effective and provides thoracolumbar stability. Furthermore, this has been identified to be an effective technique for preventing intraspinal scar proliferation.

Non-dysraphic intradural spinal cord lipoma: case series, literature review and guidelines for management

PURPOSE

Non-dysraphic intradural spinal cord lipomas are rare lesions and the management remains controversial. We present our experience with five cases and propose guidelines for their management.

METHODS

Five patients who underwent surgery for non-dysraphic spinal cord lipomas between January 2004 and April 2009 were retrospectively reviewed. All had varying degrees of neurological symptoms at the time of surgery with characteristic features on magnetic resonance imaging (MRI). All patients underwent decompression with a laminectomy/laminoplasty and debulking. The dura was primarily closed in one patient. The literature was also extensively reviewed regarding these rare lesions and optimum management guidelines proposed.

RESULTS

The age at presentation ranged from 17 to 52 years (mean 32.2). Minimum follow-up was 8 months and maximum follow-up was 5 years. There was neurological improvement following surgery in all cases. Post-operative MRI scan showed evidence of significant residual tumour in all patients.

CONCLUSION

The extent of surgical resection does not necessarily correlate with clinical outcome. The aim of surgery should, therefore, be adequate decompression with preservation of neural structures. Aggressive debulking should be avoided. Onset of any neurological symptoms/signs, bowel or bladder symptoms or intractable local symptoms should be an indication for surgery.

Outcome of osteoplastic laminotomy for excision of spinal cord tumours

PURPOSE

To evaluate the outcome of osteoplastic laminotomy after excision of primary tumours of the thoracolumbar and lumbar spine.

METHODS

Records of 10 male and 11 female consecutive patients aged 15 to 57 (mean, 37) years who underwent osteoplastic laminotomy for excision of spinal cord tumours in the thoracolumbar (n=13) and lumbar (n=8) spine were reviewed. After tumour resection, the removed posterior elements were reattached to the superior and inferior processes using anchoring sutures. Pre- and post-operative functional status was retrospectively graded according to the modified McCormick scale. Spinal deformities were classified as sagittal and coronal malalignment, segmental instability, and spondylolisthesis.

RESULTS

The mean follow-up duration was 43 (range, 12-108) months. The mean number of laminae excised was 1.3 (range, 1-4). At the final follow-up, the modified McCormick scale score improved in 16 patients, remained unchanged in 4, and deteriorated in one. No patient developed any severe complication, recurrence, spondylolisthesis, or aseptic necrosis of grafted laminae. In 2 patients their spinal deformities became worse: one had segmental instability of 17 degrees at L3-4 secondary to non-union of the L3 lamina; the other (with type-I neurofibromatosis and dystrophic deformity) underwent fusion for severe low back pain and lumbar kyphosis and progressive rotational dislocation, despite union of the grafted L2 lamina.

CONCLUSIONS

Osteoplastic laminotomy preserves the structures that could be important for spinal stability and may reduce the risk of deformities. Anterior strut grafting and posterior fusion may be necessary in neurofibromatosis patients with dystrophic deformities.

Exploration and decompression of the spinal canal using split laminotomy and its modification, the "archbone" technique

OBJECTIVE

To develop a novel minimally invasive approach suitable for exploring different pathologies located in the spinal canal, allowing moderate enlargement of the canal with preservation of the majority of posterior structures so muscle attachments remain intact and postoperative complications are reduced.

METHODS

The authors developed a multilevel spinous process splitting and distracting laminotomy technique with or without complementary corticocancellous iliac crest "archbone" autografting. Technical details are discussed. The multilevel spinous process splitting and distracting laminotomy technique with or without complementary iliac bone grafting was used in 19 patients with different pathologies of the spinal canal.

RESULTS

Satisfactory surgery of the lesions located within the spinal canal, especially intramedullary, was achieved in all patients using this new approach. The affected area of the spine was cervical in seven patients, cervicothoracic in four patients, thoracic in five patients, and thoracolumbar in three patients. The average number of split laminae was three (range, 2-6). Histological results were as follows: seven intramedullary astrocytomas, eight ependymomas, two cavernous hemangiomas, one dural arteriovenous malformation, and one hemangioblastoma. Of the eight ependymomas, 75% were removed completely and 25% were partially removed. Of the seven astrocytomas, 28.7% were removed completely, 14.3% were removed subtotally, and 57% were partially removed. The cavernous hemangiomas and the hemangioblastoma were completely removed. The approach used did not affect the extent of resection or neurological outcome. The spinous processes were closed directly in 13; in six cases, a tricortical iliac bone graft was placed between the facing bony parts of the spinous processes. The mean duration of splitting and distracting the spinous process was 16 minutes (range, 11-28 min) for the first process and 8 minutes (range, 5-14 min) for each additional spinous process. The mean duration of the whole surgical procedure, including intraspinal surgery, was 159 minutes (range, 90-290 min). The mean blood loss was 158 ml (range, 48-442 ml). The average length of hospital stay was 7.2 days. The average follow-up period was 15.4 months. Fifty-one of the 57 (89.5%) spinous process computed tomographic scans demonstrated bony healing with or without a graft between the osteotomized faces. Of the 57 spinous process computed tomographic scans, fracture of the spinous process was seen in nine (15.8%) and traumatic bony changes of the body of the vertebra in the midline in three (5.2%); these were without clinical significance and they later showed complete healing.

CONCLUSION

This surgical approach fulfills the requirements of other laminotomy techniques and helps prevent damage to the crucial posterior stabilizers of the spine. In contrast to conventional spinal canal approaches, preservation of the majority of posterior structures leaves muscle attachments on the spinous processes and laminae completely intact. Furthermore, the technique for exposure and decompression of the spinal canal is a suitable method for all spinal segments, the cervical, thoracic, and the lumbar spine in all age groups.

The transverse placement laminoplasty using titanium miniplates for the reconstruction of the laminae in thoracic and lumbar lesion

Laminoplasty for thoracic and lumbar spine surgery enables surgeons to preserve the posterior arch of the spine while preventing invasion of hematoma and scar tissue, postoperative instability, subluxation, and kyphotic deformities. The authors have developed a new surgical technique: namely, transverse placement laminoplasty (TPL) using titanium miniplates. Eight patients and 18 laminae underwent TPL using a titanium mini-plate. The preoperative diagnoses were six intradural tumors, one ossification of a yellow ligament and one spontaneous spinal cord herniation. The mean blood loss was 219 g and the mean duration of surgery was 3 h and 54 min. The mean postoperative follow-up period was 2 years and 1 month. All eight patients started to sit with a soft brace within the second postoperative day, and were able to walk within the fifth postoperative day. There were no cases of spinal deformity, an invasion of hematoma or scar tissue into the spinal canal on magnetic resonance imaging, or back pain. TPL simultaneously enables surgeons to obtain sufficient field of vision and rigid early fixation of the reduced lamina at the time of surgery. Moreover, our novel technique also simplifies the postoperative treatment, while preserving the posterior arch of the spine, and also preventing an invasion of a hematoma and scar tissue, postoperative instability, subluxation, and kyphotic deformities.

Spinal intramedullary lipoma: report of three cases

STUDY DESIGN

Case report.

OBJECTIVE

To report three cases of spinal intramedullary lipoma seen in the last 10 years and present the clinical characteristics and surgical outcome of these cases.

METHOD

Two patients were boys aged 12 years and 7 months, respectively. The other was a female patient aged 6 months. Chief complaints were hemiparesis, back swelling and thoracic scoliosis. All patients were diagnosed with magnetic resonance images. The lesion was located in the cervico-thoracic spine (foramen magnum to T1) in one case, thoracic spine (T9-T12) with the back swelling at L2-4 level in the second, and in the third, one mass extended from C6 to T11 and the other mass was located in the L1-2 level, separately.

RESULT

All masses were removed subtotally and dysraphism was absent. Postoperatively, neurological status of the first and the second patient were unchanged, but in the third case weakness was transiently aggravated.

CONCLUSION

Intramedullary lipoma is a rare spinal lesion and multiple intramedullary lipoma is extremely rare. Treatment principle is surgical decompression before symptom progression. Laminoplastic laminotomy is an appropriate approach for decompression of an intramedullary lipoma.

Cystic spinal cord tumors: magnetic resonance imaging correlated to histopathological findings

We report the characteristics of magnetic resonance imaging (MRI) of cystic intradural extramedullary spinal cord tumors (cystic neurilemmoma, epidermoid cyst, and enterogenous cyst). T1-weighted MRI enhanced with gadolinium-DTPA clearly demonstrated the rim morphology of these tumors. The comparison between the rim enhancement pattern and histopathological findings offered possible qualitative diagnosis of these cystic spinal cord tumors by MRI.